What are the recommended protocols for monitoring and managing patients post-ICU discharge in primary care?

Recommended protocols for monitoring and managing patients after discharge from intensive care in primary care include:

• Ensure continuity of care by coordinating the patient's rehabilitation care pathway with appropriately competent healthcare professionals, which may include primary care providers liaising with specialist and community services.
• Provide patients and their families or carers with comprehensive information at discharge, including details about physical recovery, ongoing treatments, managing daily activities, and local support services. Patients should receive a copy of their critical care discharge summary.
• Arrange a functional reassessment 2 to 3 months after discharge from critical care, ideally face-to-face, to evaluate physical, psychological, cognitive, and social care needs. This reassessment should be performed by healthcare professionals familiar with critical care rehabilitation.
• Based on reassessment, refer patients to appropriate rehabilitation or specialist services if recovery is slower than expected or if new physical or non-physical morbidities are identified.
• Provide support for patients not recovering as anticipated, including managing anxiety, depression, or post-traumatic stress disorder (PTSD) according to NICE guidelines.
• Encourage use of structured and supported self-directed rehabilitation programmes coordinated by skilled healthcare professionals, tailored to the patient’s capacity and rehabilitation goals.
• Maintain clear communication and information sharing between hospital, primary care, and community rehabilitation services, including sharing discharge documents and care plans.
• In primary care, monitor progress against rehabilitation plans, provide educational materials, and support self-management, including psychological and emotional support as needed.

These protocols ensure holistic, multidisciplinary, and patient-centred care after intensive care discharge, facilitating recovery and addressing both physical and non-physical sequelae.

References: ¹,²,³,⁴